Protective and compensatory childhood experiences and their impact on adult mental health
Authors: Amanda Sheffield Morris, Jennifer Hays‐Grudo
Journal: World Psychiatry (2023)

Adult mental health is influenced by childhood exposure to both adverse and protective experiences. The landmark Adverse Childhood Experiences (ACE) study1 supported an association between ten categories of adversity, experienced from birth to 18 years, and subsequent physical and mental health problems. These ten types of adversity (physical, emotional and sexual abuse; physical and emotional neglect; parental divorce; domestic violence; living with household members with alcohol or substance abuse, mental illness, or criminality) were found to be common, with more than two-thirds of individuals reporting at least one. Moreover, ACEs had a cumulative or dose-response effect on multiple measures of health and well-being. Research conducted across the globe and in many populations has consistently found that exposure to ACEs between birth and 18 years alters neurobiological adaptation to stress, increasing the likelihood of difficulties in emotion regulation, impulse control, attention, and social attachments, all of which contribute to mental health problems2. A cumulative ACE score of 4 or more increases the likelihood (using adjusted odds ratios) of panic reactions by 2.5 times, depression by 3.6 times, anxiety by 2.4 times, and hallucinations by 2.7 times3. While trauma and adversity are well-established risk factors for mental illness, the protective factors that promote resilience are less well known. Research on resilience was initially focused on identifying the qualities of children who succeeded as adults in spite of childhood poverty, abuse or neglect4. More recently, researchers have begun characterizing the resilience-promoting qualities of children's environments, identifying the types of supportive relationships and resources that mitigate the effects of ACEs. Just as ACEs appear to have cumulative negative effects, protective experiences also appear to have a cumulative effect on adult functioning, lessening negative impacts. For example, in a large sample in the American Midwest, positive childhood experiences predicted less depression and better mental health among adults even after accounting for exposure to ACEs5. Much of the research on positive experiences has been limited to the presence of supportive relationships, emphasizing the importance of children feeling supported and safe as a counterbalance to the feelings of stress associated with ACEs6. Numerous studies indicate that positive experiences during childhood set the foundation for adult mental health. We have identified ten specific protective and compensatory experiences (PACEs) that promote positive outcomes in the face of adversity, as well as overall healthy development2, 7. Like ACEs, we assess PACEs as experiences that occur prior to age 18. PACEs are categorized into two domains: supportive relationships and enriching resources. Supportive relationships include unconditional love from a caregiver; having a best friend; volunteering in the community; being part of a group; and having a mentor. Positive parenting, social support, and belongingness have been found to facilitate the development of children's empathy, self-regulation and social skills. Our second domain, enriching resources, include living in a safe home where needs are met; getting a quality education; having a hobby; being physically active; and having rules and routines. Both animal and human studies point to the importance of enriched environments for learning, managing stress, and avoiding risky behaviors.8 Research on PACEs specifically indicates that adults who report more PACEs typically report fewer ACEs, suggesting that protective relationships and resources are less available among children who experience family dysfunction and maltreatment. More PACEs are related to less depression, anxiety, substance use, difficulties in emotion regulation, and life stress. Moreover, PACEs protect adults from depressive symptoms, such that greater PACEs weaken the link between ACEs and depression, acting as a pro­tective factor in adulthood2. There is also evidence that PACEs can affect parenting attitudes and behaviors. For example, PACEs have been found to act as a buffer between negative parenting attitudes and adverse childhood experiences2, 8. Similarly, PACEs have been associated with greater resilience and less stress during pregnancy (e.g., future worries about parenting9). Taken together, these findings suggest that PACEs buffer the deleterious effects of ACEs on adult functioning and mental health. We have identified specific PACEs for different age groups (infants and toddlers, teens and young adults, school-aged children2). However, the foundation for PACEs remains the same – relationship and resources – and the basic idea of each PACE is similar. For example, having a best friend in early childhood is having opportunities to play with a child or a sibling of a similar age. PACEs can be used as a tool for adults to help children handle stress, and this may be particularly important during times of chronic and extreme stress, such as the COVID-19 pandemic. On the other hand, parents' stress and mental health are largely influenced by their children's well-being and mental health, and strategies that promote optimal parenting can have a major impact on parents' own functioning2. The PACEs Heart model corresponds to the ACEs pyramid model, which posits that ACEs lead to disrupted neurological development; social, neurological and cognitive impairment; adoption of health-risk behaviors; disease, disability and social problems; and early death1. The PACEs Heart model posits that supportive relationships and resources lead to optimal neurological development; social, emotional and cognitive functioning; healthy behaviors; achievement of developmental milestones; and health and longevity8. These models integrate developmental science, clinical psychology, and mental and physical health research, by detailing possible life course trajectories that stem from childhood experiences. Fairy tales, folklore and myths from around the world are replete with examples of the youthful hero or heroine's journey from adversity and despair to triumph and success, supporting the empirical evidence that the path to resilience is paved with protective relationships and resources. What is lacking from many trauma-focused interventions is an acknowledgement that PACEs are powerful elements of everyday life that already exist, or can be engineered to occur routinely and frequently, and can be leveraged to support treatment goals and activities. Our research indicates that adults can benefit from current PACEs as well as previous experiences from childhood. We have created an Adult PACEs Plan that encourages adults to choose one or two PACEs to work on each month with a group of adults. As with PACEs for children of different ages, adult PACEs focus on relationships and enriching experiences2. Anecdotally, we have found that individuals benefit from focusing on simple activities that strengthen relationships and impose structure and routine. In summary, PACEs are often overlooked but powerful tools, that can support therapeutic interventions and mental health throughout the life course.